The focus of this blog is on the wonders of government-run health-care everywhere but I also note the damage done to private medicine by a legal system that supports predatory litigation.

The long-established socialized medicine systems in Britain and Australia are a particularly relevant warning about where such systems end up.

Posts by John J. Ray (M.A.; Ph.D.)

Saturday, January 31, 2009

AUSTRALIA'S PUBLIC HOSPITAL MELTDOWN CONTINUES

Three current news reports below

Big deal: NSW hospital death "not from lack of beds or staff"

But it obviously WAS due to insufficient diagnostic testing -- scans etc. There is no reason why diagnostic imaging could not have been done same day. That was once routine and still is in some hospitals

The NSW Government has apologised to the family of a man who died a day after being discharged from hospital, but says his death was not due to a lack of beds or medical staff. Brendan Burns, 24, was discharged from Griffith Base Hospital on Monday with a bad headache and died the following day at Sydney's St Vincent's Hospital from an undiagnosed brain tumour. Greater Southern Area Health Service (GSAHS) Chief Executive Heather Gray yesterday said the matter was being investigated, and would also be referred to the Health Care Complaints Commission.

Health Minister John Della Bosca today apologised to Mr Burns' family but said his death was not linked to staffing levels nor patient capacity at Griffith. "I extend my commiserations to his family, I feel deeply sorry that this has happened," Mr Della Bosca said. "All the evidence I have is that there was a great deal of professional skill involved in the handling of the case. "My advice is there was no bed shortage ... there was no staff shortage."

GSAHS said the man arrived at Hay Hospital on Sunday and was transferred to Griffith Base Hospital on Monday. He was discharged in the early hours of Monday, went home and returned to Hay Hospital that same morning. Later on Monday, the man was flown from Hay Hospital to St Vincent's where he died on Tuesday.

Tammy Hams thought she was "going to die" when she was offered a blanket and told to lie on a waiting room floor because staff at her local hospital could not find her a bed. Ms Hams was booked in for surgery at Wyong Hospital to remove possible cancerous lesions when doctors discovered a huge abscess causing "agonising pain". The 29-year-old said she spent 3« hours writhing in agony on the waiting room floor of the hospital's surgical ward on Wednesday before she was eventually given a bed. Staff at the hospital "categorically deny" her claims. [But see picture above]

The incident comes amid yet another hospital outrage, in which a 24-year-old man was discharged from Griffith Hospital early on Monday after complaining of sinus pain. The following day he again presented to the hospital and was flown immediately to Sydney's St Vincent's where he died from unknown causes. Greater Southern Health has launched an investigation into why he was discharged. And in Dubbo, doctors are threatening to quit because they routinely run out of basic medications.

Ms Hams said her GP had been trying to get her into hospital since Friday when she began feeling stabbing pains in her stomach. A biopsy four months ago revealed pre-cancerous lesions on her cervix, which if left would turn cancerous. "I thought I was going to die," Ms Hams told The Daily Telegraph yesterday from her hospital bed. "I have never been in that much pain in my life - it was agony."

She was booked-in for a hysterectomy and told to arrive at 9am. Her mother Jenny Leatham said she was "crying and doubled-over in pain" and could not sit on the waiting room chairs or stand, so they pleaded for a bed. "They gave her a blanket and said the best she could do was lie on the floor," Mr Leatham said. "The staff were so nice and you could see they were upset about what was happening. This is just unfair, I'm not rubbishing the staff. There just wasn't enough beds. "The system has to change."

A North Sydney Central Coast Health spokeswoman said an investigation found there was no shortage of beds and Ms Hams was "treated in a caring and timely manner". "It is unacceptable for a patient to be expected to lie on the floor and staff on duty when Ms Hams arrived at the hospital deny making any such recommendation," the spokeswoman said. The hospital argues she was assessed by an anaesthetist at 10.10am and that she asked for the blanket.

Mrs Leatham said by 12.30pm staff found her daughter a bed and she was operated on at 2pm. When surgeons cut her open they discovered a huge abscess pushing on her cervix. Unable to perform the hysterectomy they removed as much of the infection as they could and inserted a tube to drain it over the next seven to 10 days.

"If the abscess had burst while she was in the waiting room she would have died," Mrs Leatham said.

Wyong Hospital is just one of the state's many hospitals plagued with debt, bed shortages and a lack of specialist doctors. Last week its emergency department - one of the busiest in the state - lost all but one of its specialist doctors to Gosford Hospital so it could retain its status as a teaching hospital.

Senior doctors at Dubbo Base Hospital threatened to walk off the job after they ran out of morphine because the hospital could not afford to pay pharmaceutical companies. Patients in intensive care also sweltered for days in record temperatures because contractors could not be paid to fix the air conditioning.

The Greater Western Area Health Service reportedly owes more than $23 million to suppliers. Many are no longer prepared to provide food or medical equipment. The situation across the state is expected to get far worse before it gets any better. A report by auditing firm PriceWaterhouseCoopers last month revealed the state's health budget would blow out by as much as $900 million by March if dramatic changes were not made.

Queensland public hospitals have worst record for killing, maiming patients, botched operations

Queensland Health is a most obnoxious bureaucracy to work for so they are able to attract high quality staff in relatively small numbers only. The rest are often the dregs with nowhere else to go -- and it shows in the quality of their work

QUEENSLAND hospitals have the nation's worst published record for killing or maiming their patients through botched operations, medication errors and other mistakes. And NSW is one of the safest, reporting a third fewer serious errors despite its larger population.

The figures, released in a Productivity Commission report, provide a rare state-by-state breakdown of so-called "sentinel events" - the most preventable and potentially deadly mistakes that occur every year in the nation's hospitals, The Australian reports. Last year, the Australian Commission on Safety and Quality in Health Care reported that sentinel events - ranging from discharging an infant to the wrong family to suicides by admitted patients - more than doubled nationally in 2006-07 compared with a year earlier.

The mistakes accounted for just 10 per cent of serious hospital errors recorded by the states and territories but made public only selectively. But of the 187 deadly or damaging lapses in judgment or procedure made public yesterday, Queensland accounted for over a quarter of the national total.

Its hospitals carried out procedures on the wrong patient or body part an alarming 33 times in 2006-07. They killed another six patients through medication errors, seriously injured or killed four mothers in childbirth, left surgical instruments or material inside three patients, and transfused incompatible blood once.

The next worst offender was Victoria (45), which was slammed by its Auditor-General last year for failing to adequately monitor hospital blunders. Some 135,000 patients - or one in 10 public hospital patients - in that state had endured a medical mistake, with more errors believed to have gone unreported. South Australia, with 36 sentinel events, was next in line, followed by NSW (32), Western Australia (15), the ACT (7), the Northern Territory (2) and Tasmania (1).

"A high number of sentinel events may indicate hospital systems and process deficiencies that compromise the quality and safety of public hospitals," the Productivity Commission said. The willingness to report major mistakes could also influence the totals, it noted.

Friday, January 30, 2009

Plan for a green NHS is crazy and dangerous. Britain just need a health service that works

Seemingly oblivious to events in the real world, Whitehall's green crusaders have found themselves another target: the beleaguered NHS. Now, you may have been under the illusion the health service had enough to worry about, saving lives, delivering babies and generally tending to the sick. Wrong! It is responsible for 18million tons of carbon dioxide emissions each year, 3.2 per cent of the total for the whole of Britain. Something must be done! Thus the NHS has dreamt up a strategy, complete with barmy and in some cases apparently dangerous ideas, which will reduce its 2007 emissions by 10 per cent by 2015 and - God help us - 80 per cent by 2050.

So, the next time you are feeling unwell and want to make an appointment with your GP, expect to be asked if you wouldn't settle for some 'telemedicine' instead. Or, sparing the jargon, how about telling your doctor what is wrong over the phone, rather than a face-to-face appointment with stethoscopes and the like, in order to avoid getting in your car, and chugging out carbon dioxide as you cough and splutter over the steering wheel? Sure, you risk misdiagnosis - but think about the good you'll be doing the environment. Feel better already? Thought so.

And what about cutting out the red meat, should you ever be unlucky enough to find yourself hospitalised? Yes, you might be at a low ebb, and in need of a decent meal. But it is very energy intensive to produce a steak, so how about settling for some vegetables? Removing meat from the hospital menu will do the planet good, if not you.

On the nonsense goes. I'm prepared to give them the idea of using tap water instead of bottled. I fell for the fad of lugging dozens of bottles of the stuff home from the supermarket a few years ago and, like most people, have since got over it. But the majority of the green strategy is preposterous, nannying and not without risk. As Michael Summers, of the Patients Association, said: 'I believe this is fraught with danger, and many GPs see it as a dangerous practice. 'There are cases of patients having died after being misdiagnosed over the phone.'

Speaking to your GP over the phone can be reassuring in non-urgent cases - but how can a GP know if it's urgent or not without seeing them?

Even if you accept that Britain must reduce its carbon emissions, in order to lessen the impact of climate change, the NHS is entirely the wrong target. (I'd suggest axing the bureaucrats responsible for thinking up such initiatives. Think of the petrol and light bulbs you could save).

Yes, people have a duty to think about the world we'll bequeath to future generations. But not when they're sick. Nor should those faced with the difficult task of treating the ill, or helping the terminally-ill to die with dignity, have to give a second thought to their carbon footprint. Rather, they should be allowed to concentrate on addressing the failings which - despite the sterling efforts of those on the frontline - remain all too abundantly clear.

Let's take a look at some revelations from the NHS over the past three weeks alone. Two out of three hospitals still have mixed-sex wards, 12 years after Labour promised to get rid of them. Seventy per cent of trusts say men and women are not properly segregated on their wards, where they are often separated by nothing more than a curtain or a flimsy partition. Just 15 per cent of hospitals ensure all patients have fully separate wards and bathroom facilities. Isn't this a little more important than worrying about lightbulbs?

The number of patients killed by hospital blunders has soared by 60 per cent in only two years. Official records show that 3,645 died as a result of outbreaks of infections, botched operations and other mistakes in 2007/08. That was up from 2,275 two years before. Shouldn't the NHS be devoting its time to reducing this figure, rather than keeping beef pie off the hospital menu?

Midwives are more overworked than they have been for at least a decade, and are delivering far more babies per year than stipulated by safety guidelines - putting mothers and babies at risk. Experts believe up to 1,000 babies a year die needlessly because doctors and midwives are too overstretched or poorly-trained to detect warning signs. Do these same poor midwives really need some bureaucrats encouraging them to cycle to work, in order to reduce their carbon footprint?

Thursday, January 29, 2009

THE LATEST ON AUSTRALIA'S PUBLIC HOSPITAL MELTDOWN

Three articles below

Another deadbeat public hospital in NSW

Outstanding bills which have seen a security firm threaten to withdraw its services from a rural NSW hospital will be paid within 24 hours, the state government says. Health Minister John Della Bosca said he had spoken to Greater Western Area Heath Service (GWAHS) chief executive Dr Claire Blizzard, who gave an assurance the bills would be paid imminently.

Heartland Security threatened to halt work at Parkes Hospital if the bills were not paid by today. The firm also has complained about a string of late payments by the health service last year.

"I've been advised by the GWAHS by Dr Blizzard ... that she will be paying within 24 hours the outstanding account to the security firm involved," Mr Della Bosca told reporters in Sydney.

The work performed by the security personnel includes escorting nurses to their cars at the end of a night shift, to offer protection against possibly violent patients. Mr Della Bosca said there were three outstanding bills from the security firm, and only one from November was outside the new benchmark of 43 days in which a bill should be paid. But the latest case of late-payment also follows reports of staff at Mudgee Hospital using petty cash to buy sausages after a butcher refused to supply further meat, and a cancellation of surgery at Orange Base Hospital when it ran out of syringes.

Mr Della Bosca said the outstanding accounts at the GWAHS totalled $60 million when he took on the health portfolio, and they now stood at $23 million. "It has more than halved in four months so that is a very good trend line,'' he said. "I expect that to continue. I expect the GWAHS will achieve the benchmarks that we require for payment of local businesses and suppliers.''

Easy interpretation: His brain is so constipated with failed Leftist ideas that he hasn't got a clue what to do

Doctors at Dubbo Base Hospital have not been paid for weeks, nurses at Orange are using their own money to buy batteries for heart monitors and cake trays to dispense pills, and students in Mudgee have bought beds for the emergency department as more reports of the state's credit meltdown come to light. But a spokesman for Nathan Rees said yesterday the Premier was "too busy with other things" to deal with the issue. The Director-General of NSW Health, Debora Picone, refused to comment, saying the Greater Western Area Health Service "managed itself".

The area health service, which covers 56 per cent of the state, is in crisis after more reports that creditors are waiting up to six months to get paid, deliveries of food and medical supplies to hospitals have been cancelled and vital maintenance work, such as fixing blocked pipes and faulty lifts, is not being carried out.

About 12 creditors came forward yesterday, including one owed more than $16,000 for delivering fruit to remote hospitals and a nurse who was angry that several wards at Orange Base Hospital had been without paper towels, vital for infection control, for several weeks because unpaid suppliers had stopped deliveries

Their claims came after the Herald reported a Parkes security firm was threatening to withdraw its services if its $6000 bill was not settled within 24 hours. Its owner, Lindsay Harvey, said he was told yesterday his money would be in his bank account by this morning. Steve Miller, the owner of Country Fruit Distributors in Dubbo, owed $14,000 for three months, was also paid about $7000 yesterday after complaining to the Herald.

The chief executive of the Greater Western Area Health Service, Claire Blizard, said it was "clearly unacceptable that some creditors are facing these delays". "We have made progress in relation to the payment of creditors and in the past couple of months we have made a 50 per cent reduction in creditors owed money. This is not a problem that can be fixed overnight," she said.

Students from Mudgee High School ran car washes, charity balls and raffles to raise $20,000 for emergency department beds last year. "It's a bit of a shame really that in a country like ours, as rich as ours, that our Government's health system has to rely upon local community donations to keep the hospital running," the former school captain, Hannah Kempton, said. Three emergency trolleys were bought by the hospital's auxiliary last week after it raised more than $15,000 in raffles, while a football team paid for carpet in the maternity ward. "It would be nice if we didn't have to buy these things, but we do," the president of the auxiliary, Glenys Goodfellow, said.

The Opposition health spokeswoman, Jillian Skinner, said it was unacceptable. "If people don't pay their speeding fines or taxes on time, then they get taken to court or there's some penalty. Why should the . Government think it's the exception?"

The hugely bureaucratized Queensland Health are such unpleasant people to work for that they have to employ any scum to fill the gaps that their bloodymindedness creates in their workforce

A Pakistan-trained doctor will face a tribunal after allegedly performing an unnecessary vaginal examination on a patient. The Queensland Medical Board referred Naseem Ashraf to the Health Practitioners Tribunal earlier this month, claiming he had engaged in "unsatisfactory professional conduct" that may require disciplinary action.

Ashraf, who is no longer registered as a doctor in Queensland, was working as a senior medical officer and anaesthetist at Mount Isa Base Hospital in October 2004 when the misconduct allegedly took place. It is alleged Ashraf performed an intra-vaginal examination on a woman who had visited him for a pre-anaesthetic consultation. The woman was due to undergo surgery one week later to remove abnormal cells detected during a routine pap smear.

According to a referral notice filed by the Queensland Medical Board in the Brisbane District Court, the vaginal examination was not required for a pre-anaesthetic assessment. The board also is claiming Ashraf did not gain the woman's consent before conducting the examination, or keep adequate medical records. Ashraf will face the tribunal at a later date.

Wednesday, January 28, 2009

Parents' grief as daughter dies after NHS hospital 'forced them to change her treatment'

The father is a very forgiving man. He should sue the pants off the arrogant b*stards. It's the only thing that will get their attention. Arrogance is a hallmark of the NHS

A little girl with a very rare medical condition died after a hospital threatened her parents with a police protection order if they did not comply with a new treatment plan, it has been claimed. Francesca Blair-Robinson, 12, died five months after her father says he and her mother were forced to withdraw their opposition to new treatment.

Father Malcolm, who had taken the lead in his daughter's care, believes the change in treatment led to her death and that Francesca would be alive today if his hand wasn't forced with the threat of police intervention. Last night the devoted father-of-six spoke out about the tragic circumstances of his daughter's death, calling for a change in the way vulnerable children are treated.

Speaking of the hospital's decision to pursue a 'much more aggressive' therapy plan he said: 'I had warned in writing that such a medical approach may prove fatal, based upon the fact that I had been Francesca's full-time carer for almost the whole of her life and had studied her medical condition and her response to treatment 24/7 for 11 years. 'I have conducted significant research into her case since her death and I am entirely satisfied that the treatment killed her and that neither I nor her mother nor Francesca herself would have agreed to this approach but for the intervention of child protection procedures.'

When Francesca was born with a rare congenital syndrome causing a catalogue of symptoms, including being very small and frail, it was feared she would not make it to the age of one. Sent home to die she confounded expectations by surviving under the dedicated care and attention of her family. Her novelist father, 69, became her full-time carer, devising a treatment plan by 'trial and error' but tailored to her needs that included antibiotics, a nebuliser, physiotherapy and a special diet.

Mr Blair-Robinson, who split from Francesca's American businesswoman mother in 2004, said: 'Working closely with doctors we not only saved her life but developed therapies through cautious use of drugs which gave Francesca a quality of life, a richness of experience and an inspirational nature that was little short of a modern day miracle.' Although weak, the little girl was able to go to school for short periods, and have a home tutor for the rest of the time. She developed a network of friends on the internet and loved the countryside. But after moving from Surrey to West Sussex in 2006 the doctors overseeing Francesca's care changed.

When she collapsed in May 2007 medical staff at St Richard's Hospital, in Chichester, wanted to change the way she was treated. She made a swift recovery but doctors still advocated 'aggressive use of IV antibiotics' and oxygen therapy, claims Mr Blair-Robinson. He said both he and his ex-wife objected, and within a week were summoned to a meeting where they were confronted without warning by a social worker, police officer and medical staff. 'Her mother and I were threatened that unless we withdrew our opposition to the hospital's medical plans, Francesca, a frail and vulnerable child with a very sharp intellect, would be made the subject of an immediate police protection order.'

Terrified the couple complied and the little girl was referred to Southampton General Hospital which set out the more 'aggressive' programme. Within five months she had died of respiratory failure, a death that Mr Blair-Robinson would not have happened if he had been allowed to continue taking the lead in her care. He believes there should have been a narrative record of her care in her medical notes and a better system of information sharing and is calling for an overhaul of the way the NHS handles complex cases of children with special health needs. 'She knew she was dying, insisted on doing her Christmas shopping early as she feared she would not reach the day herself and confided that she felt the doctors were killing her.'

He said he did not indeed to pursue legal action as he did not think it 'helpful'. 'Doctors do their best but they make mistakes, they are human,' he said. 'They are forgiven but changes need to be made.' He is sending a copy of his proposed reforms to child protection process to Downing Street.

Of Francesca, who he believes could have survived into adulthood, he said: 'She was a completely magic person, everybody who came upon her was enchanted by her, she may have had a wonky body but she had a golden spirit. 'So that the values of her life may be more widely shared, it seems fitting to propose reforms to our approach to helping the vulnerable.' Francesca had congenital varicella syndrome, a condition that is related to the mother being infected with chickenpox early in pregnancy.

Tuesday, January 27, 2009

Medically-caused illness cured by a dedicated British mother

There is no doubt that antibiotics are overused. Sensitivity to them is supposed to be routinely monitored -- but this is the NHS, of course

A baby with a mysterious condition which causes his stomach to swell has been cured by a probiotic drink, his mother says. Riley Anderson, who is 11 months, has struggled with the bloating syndrome since birth. Doctors first noticed the problem when he was just 12 hours old and Riley was taken to a special baby unit. He was fed by a tube and later transferred to a specialist children's hospital, but no one could work out what was wrong with him.

His mother, Anna Anderson, 35, said: 'They didn't know what it was and sent us home. 'They still don't know what it is. He was bloated and his stomach was nearly as big as his body, it was like a balloon.' The problem continued for months. Miss Anderson, who has three other children, added: 'He was bloating up and being sick and if he did need to go to the toilet he was constantly screaming. 'I changed his milk to see if that would help, but it didn't, he was still bloated.'

As doctors could not help her, Miss Anderson decided to do some research herself. When she explored the antibiotics that Riley had been given by doctors, she discovered that one of them kills natural bacteria in the body. As a last resort, she decided to try and reintroduce this bacteria to her son by feeding him bottles of probiotics. 'I gave him Yakult and he was fine within the first couple of days of him having it,' she said. 'He was ten months old, and at his happiest he had been. There was no bloating.'

A few weeks later, Riley had problems with his ears, and was taken to hospital, where he was given more antibiotics. But after just two doses, his stomach began to swell again. Once he was home, his mother, from Aby, Lincolnshire, began to dose him with Yakult and he returned to normal. 'I think there is a bacterial imbalance in his stomach which means he can't digest food, and the Yakult helps get that back,' she said. 'When I give him Yakult, it settles his stomach and he is fine.'

Dr Henry Mulenga, a member of the Royal College of Paediatricians, with a special interest in gastroenterology, said: 'We are beginning to hear more and more of these type of stories. In my view it is very possible. 'There is no doubt that some conditions can be improved by introducing healthy bacteria. 'Many parents may feel that is the case. The difficulty we have with very small babies is whether it is entirely safe to do so.'

A spokesman for Yakult said: 'We are delighted that our product has helped in this circumstance.'

Monday, January 26, 2009

Australia: Public hospital management and staff pass the buck

A FOUR-YEAR study of NSW hospitals has revealed staff and senior health bureaucrats blame each other for shocking errors, including deaths of patients. The statewide "safety check" found patients were at significant risk of death or injury from falls, medication errors, staffing levels, lax infection control and mistakes in diagnosis and treatment.

Doctors and nurses overwhelmingly agreed that chronic understaffing and heavy reliance on inexperienced junior staff was a major risk - especially after-hours and in complex areas such as emergency and intensive care. But the area health service managers blamed adverse incidents on mistakes made by medical and nursing staff rather than problems with skill mix.

Opposition Health spokeswoman Jillian Skinner said it was "scandalous" that it has been five years since the Walker inquiry into 21 deaths at Campbelltown and Camden hospitals recommended an urgent audit of risks in the health system. Since then internal reports into 85 deaths over two years at western Sydney hospitals revealed that at least 49 of the patients did not receive adequate care.

Most of the avoidable deaths were due to a delay in responding to a rapidly deteriorating patient, the Annual Review of Root Cause Analysis 2006 and 2007 found. But the chief executive of the $55 million Clinical Excellence Commission, Professor Clifford Hughes, defended the Quality Systems Assessment report released today, saying a great deal of developmental work had been done to get an accurate picture of the state's complex health system. Professor Hughes said allowing everyone from the ward staff to hospital managers to top-level administrators to nominate their three highest risks to patient safety showed there was a significant disparity between the issues front-line staff saw as important, and the priorities of management.

The report found dozens of patient safety programs had been implemented since 2004 but very few had been reviewed to assess if they actually worked. Four of the eight area health services, and the Children's Hospital at Westmead, did not have any systems or processes for reviewing deaths. It also found confusion and lack of clear policy in many areas.

The director of the Institute of Health Innovation at the University of NSW, Jeffrey Braithwaite, commended the report but said collecting information was just the first step. "On too many initiatives in NSW we've seen things chopping and changing."

Health Minister John Della Bosca said 89 per cent of respondents felt there had been an improvement in patient safety and quality culture in the past two years. "This rigorous program is a world first for the assessment of quality and safety processes in a health system that will help us achieve ongoing improvements."

Sunday, January 25, 2009

The fallacy of healthcare reform as economic stimulus

After spending decades trying to reduce health care costs, some commentators and policymakers now argue that health care costs should be increased to stimulate the economy.[1] At the crux of the argument are the notions that increasing spending on health care will create jobs that can be filled by those losing jobs in other areas of the economy--and that implementing long-proposed reforms (such as an increased emphasis on primary care and large-scale deployment of health IT) will reduce health care costs.

These two arguments are fundamentally at odds with each other. Advocates claim simultaneously that (a) it would stimulate economic growth to spend more money on these reforms, and (b) these reforms would reduce total health care costs--that is, result in spending less money. Perhaps one could make an intelligent argument for either proposition, but it is not possible to make both of those claims and be consistent.

Two Sides of the Same Coin

The entire proposal rests on the assumption that one can get a "free lunch" by looking at only one side of the ledger--by counting the benefits of reform but ignoring the costs. Health care jobs are clearly a benefit to workers who would otherwise have worse jobs or no jobs at all, but as long as employees need to be paid, one person's job is also another's cost. Artificially increasing the number of health care jobs also artificially (and wastefully) increases health care costs. On the other hand, reducing total health care spending means there is someone who would otherwise be paid who is either no longer being paid or being paid less--and that person is losing a job or taking a pay cut. Spending money on health care might create jobs in the health care industry but only at the cost of jobs destroyed elsewhere in the economy. In other words, health care reform might reduce health care costs, or it might create new health care jobs, but it cannot do both simultaneously.

Any money the government spends on health care (or anything else) has to come from somewhere--either higher taxes, more borrowing, or inflation--and that means less is available to the economy for private spending. Government spending cannot cause prosperity; it can only reallocate resources from one person or activity to another. Prosperity--economic expansion--can be achieved only by increasing total production, not simply moving it around. For this to occur, entrepreneurial individuals and companies have to find it worthwhile to engage in productive activity and investment. The only way government can induce sustainable economic expansion is to reduce the taxes and regulations that inhibit productive activity.

In the long run, wasteful spending will not stimulate the overall economy or improve health care; it will only divert resources that would be better used elsewhere. Health care reforms are beneficial only if they result in today's health care at lower costs, improved health care at the same or tolerably higher costs, or some combination of the two.

Increasing Spending While Cutting Spending?

Health care expenditures are taking up an ever-larger share of GDP, rising from 13.7 percent in 1993 to 16.0 percent in 2006 and forecasted to grow to almost 20 percent by 2017.[2] Proponents of reform have long argued that this trend is sucking the lifeblood out of our economy, and bound to cause or deepen a recession. And yet, now some of those same experts are arguing that, in order to get the economy out of a recession, health care spending must be increased. In essence, it is as if they are saying, "Our economy is threatened because heath care spending is too high, so to solve the problem we need to make it higher."

For example, MIT economist Jonathan Gruber says that "health care reform can be an engine of job growth," and he cites two main categories of job opportunities. First, he argues that longstanding proposals for reform of primary care would create new jobs for nurse practitioners and physician assistants, which would save money because primary care is cheaper than specialty care. Second, he cites President-elect Barack Obama's proposal to spend $50 billion on health information technology, which would create jobs in the IT sector and save money through more efficient record-keeping.[3]

However, in order for heath care reform to be "an engine of job growth," health care spending must go up, not down. After all, the main reason people like jobs is that they come with paychecks. The goal of reducing health care costs directly contradicts the "logic" of stimulus spending. The idea of stimulus through primary care reform is a contradiction: Spending will be reduced, as higher-paying specialty care jobs are replaced by lower-paying primary care jobs. Furthermore, these jobs--in serious professions requiring real expertise and years of training--would do little to improve the short-term job prospects of people laid off from other industries.

The idea that increased health IT spending will result in a permanent increase in jobs in the IT sector is a red herring. If health IT will reduce health care costs in the long run, then those new jobs in the technology sector will be more than offset by money saved--that is, jobs "lost"--in other sectors. There will be less need for file clerks and office staff and perhaps even nurses.[4] To argue that health IT is both a good stimulus and a way to reduce health care costs is in effect arguing that it is good because it creates (technology) jobs but also good because it destroys even more (health care) jobs.

Medicaid Reform as Stimulus Spending?

Some advocate Medicaid expansion as part of a stimulus package. Medicaid is a complex program in need of reform to provide better health care for the poor at a lower cost, but there is no reason to believe that Medicaid expansion would be a source of stimulus for the overall economy. The argument that it would comes in two forms.

First, some claim that expanding Medicaid eligibility would cause previously uninsured families to spend more on consumer goods, since they would not have to save for unexpected medical expenses. Gruber and Yelowitz find that previously uninsured households that become eligible for Medicaid do indeed spend more.[5] But this does not mean that total consumer spending increases--the money used to fund Medicaid expansion has to come from somewhere; in particular, whoever paid the taxes to fund the expansion had to reduce their own spending. Furthermore, the recessionary effects of taxation mean that the decrease in spending by other taxpayers is greater than the increase in spending by new Medicaid recipients.

Second, others argue that increasing federal funding for Medicaid and SCHIP would free up state money for public works ("roads and bridges"). In fact, it would do no such thing. These are matching fund programs: The states run the programs, and the federal government provides subsidies proportional to the funding provided by the states themselves. If the federal government gave states money to enroll more people in these programs, that would require states to spend less money on public works projects to meet the matching requirements. In fact, under existing law, states could already increase the amount of federal money they receive for Medicaid by choosing to spend more on their own. But they do not, because that would require cutting spending on other programs--for example, public works projects.[6]

No Free Lunch

All of these arguments still neglect the bigger picture: Any money the federal government spends on health care reform, health IT, Medicaid, roads and bridges, or anything else has to come from somewhere. And that "somewhere" is either increased taxes, more borrowing, or inflation of the currency, any combination of which would cancel out any "stimulus" effect of the new spending. Spending money on health care or "roads and bridges" might create jobs in the health care or construction industries, but that is only at the cost of jobs destroyed somewhere else. This is what economists mean when they say, "There is no such thing as a free lunch."

Prosperity cannot be achieved by simply moving resources around from one sector of the economy to another. Rather, it can be achieved only by increasing production, which can be induced not by spending but by reducing the taxes and regulations that inhibit productive activity.

NURSES guilty of manslaughter, sex offences, arson and torturing animals have been allowed to care for the sick and vulnerable in Victoria. In the past three years the Nurses Board approved registration of 103 nurses who had admitted being found guilty of crimes such as theft, stalking, drug trafficking, possessing child pornography and manslaughter. The board cancelled registration of two nurses because of their criminal pasts, while the results on another three nurses are unclear, the Herald Sun reports.

Patient advocates and the Opposition want an immediate investigation of registration of some nurses, as well as the process, in light of documents obtained by the Herald Sun through Freedom of Information requests.

But the Nurses Board says it is not concerned that at least 103 of Victoria's 86,000 registered nurses have serious criminal records. Its says its investigation processes ensure public safety. In 2006 it became mandatory for nurses to disclose their crimes when renewing their registration each year. Since then the board has been told of:

A NURSE convicted of manslaughter in 1994 whom it re-registered.

THREE nurses guilty of indecent assault who had their registration renewed.

A NURSE caught with a drug of dependence and taking it into a prison in 2005.

A HOST of theft, fraud and social security offences.

In one instance the board renewed a nurse's registration despite being aware of 19 convictions for arson. Some offences date back many years, but all were disclosed to the board after 2006.

Medical Error Action Group spokeswoman Lorraine Long accused the state's medical authorities of placing the interests of nurses above those of their patients. "The Nurses Board is looking at the rights of nurses, but the patients are part of this equation and where are their rights? Who is protecting them?" she said.

Health Services Commissioner Beth Wilson said she had not urged an investigation because the new disclosure requirements may lead to better processes. "When you get a whole lot of disclosures all at once like this you can't possibly investigate them all, particularly when some of them go back to the 1980s . . . What is more important is the nurse's record. Have they been a good nurse and are they well supervised? "It might be that sometimes people who make mistakes in their life could actually be better nurses."

Saturday, January 24, 2009

FDA madness

#1: FDA experts have voted to ban the drugs Serevent and Foradil for asthma patients. The vote isn't binding, but the FDA generally follows such recommendations. And yet . . . One-third of these experts disagreed with banning these drugs for adult patients. The leading rationale was that many patients used them incorrectly by not pairing them with a steroid. But what about patients who took the drugs responsibly and correctly? The total cost of these drugs plus steroids is still cheaper than that of two other asthma drugs, Advair and Symbicort, which were approved. In other words, the panel voted to limit the clinical options of doctors and increase the costs for patients.

Even so, it could have been worse. Some FDA safety experts wanted to ban all four drugs because they may cause one death in "somewhere between 700 and 4,000 patients." They apparently didn't listen to Dr. Richard Gower, President of the American College of Allergy, Asthma, and Immunology, who said, "We live in an imperfect world. All drugs have potential benefits and side effects."

#2: The FDA has also banned the use of chlorofluorocarbon (CFC) inhalers (MDIs) beginning this year. CFC products are believed to cause ozone depletion, and most of them were banned internationally by the Montreal Protocol of 1987. However, Medically essential products, such as CFC MDIs, have been exempt. Medical products account for, at most, 0.5% of CFC consumption, meaning the ban is not environmentally necessary. Replacement inhalers (HFAs) are still patent-protected, and no generics can be made until 2010. HFA MDIs are 2-3 times the price of CFC MDIs, and require more diligence to clean and maintain.

The poor, who are already more likely to suffer asthma, are paying a tax on their health for the sake of a symbolic environmental gesture. There is no medical justification for banning CFC MDI's....

Seventy-year old David Basey is planning to spend his life savings on a drug that could give him a few months of extra life - in the hope that the NHS will step in before it is too late. And yesterday, he and his wife confronted the group which makes drugs decisions for the NHS to ask why it has taken so long to make up its mind on four life-extending drugs for advanced kidney cancer. Mr and Mrs Basey, from Gorleston, went to the public question time held by the National Institute of Health and Clinical Excellence (Nice), the independent body which provides national health guidance.

The retired bricklayer and electricity board worker was diagnosed last February and was given one to two years to live. He has had his kidney removed but the cancer has spread to his spine. His only hope is one of the latest cancer drugs, Sutent, which could double his life expectancy and his time with his wife Ann, to whom he has been married less than a year.

But the drug is not recommended for use on the NHS apart from exceptional cases. Nice is reviewing its guidance and met to make a decision last week, but will not publish it until late March. Until then, Mr Basey has decided to spend his life savings on the 3,000 pounds-a-month drugs in the hope that the NHS will pay for them before his money runs out.

Mrs Basey, 60, asked Nice bosses why there had been such a delay - and chief executive Andrew Dillon admitted that they should have started the process much earlier. She asked: "Bearing in mind that the process has already taken years, can you tell me why there is such a delay between the meeting last week and the announcement in March? Do you realise how many kidney cancer patients are dying for the want of these drugs, or are spending their savings in the hope that it will help them? If the drugs are approved, why do PCTs [primary care trusts] then have three months to implement that guidance?"

Mr Dillon said: "We started work on assessing these drugs far too late. The guilty parties there are Nice and the Department of Health." He said that, once work started, committees had to look at all the evidence, hold a consultation, and look at new evidence. Primary care trusts are given three months to help with financial planning, although some are ready to implement it more quickly. He added: "I know it is tedious, and not just tedious, but distressing. I do sympathise with you."

Nice has been looking at Sutent, Nexavar, Torisel and Avastin since 2007. The drugs could help up to 1,700 people in Britain with advanced kidney cancer each year. It is due to publish its guidance, or final appraisal determination (FAD), in late February, followed by a 28-day chance to appeal, so if there is no appeal it will become official in March. But its new guidance on end-of-life treatments, which was published earlier this month, said it can only publish an appraisal consultation document - in which case the wait will last much longer.

Mr Basey said: "Sutent might double my lifespan. We can afford to pay for it until June and I hope by then the guidance will have changed. I hope something in medicine will come along in the time I have got left. That is my only hope."

Ian Small, deputy head of prescribing for NHS Norfolk, said: "NHS Norfolk welcomes definitive answers on the funding of drugs by Nice. This means that NHS Norfolk would pay for a drug, should it be recommended clinically appropriate for a patient by their consultant. "Nice gives guidance to all primary care trusts to say that processes should be in place to be able to prescribe to appropriate patients within a three-month window and NHS Norfolk would work in line with this."

Fellow kidney cancer sufferer Alan Martin, from Lowestoft, has been campaigning for Sutent to be widely available on the NHS. And David Blackett, from Attleborough, is one of the few to receive Sutent on the NHS as an "exceptional case" after battling to receive it.

Also at the meeting, held at the Norfolk and Norwich University Hospital, was Deborah Browne, the chairman of the N&N's drugs and therapeutics committee. She asked why there had to be a gap between the FAD and the guidance becoming official. She said afterwards: "Once the FAD is published, the patients' expectation is that it will be available. The patients are kept in limbo. That is difficult, when there is a whole group of patients that are waiting."

Friday, January 23, 2009

How arthritis sufferers are let down by NHS targets

Thousands of rheumatoid arthritis sufferers are being let down by 'unacceptably wide variations' in care by GPs and hospitals, says a report. It claims the postcode lottery is being made worse by Government targets that are causing delays in appointments to see specialists and receive treatment. Patients already diagnosed with the disease are having to wait longer to be seen - or the NHS ends up paying more than double to treat them as a 'new' patient, says the report from the independent King's Fund think-tank.

Around 420,000 Britons have rheumatoid arthritis, with more women than men affected. It causes pain, swelling and inflammation in the joints and also puts sufferers at higher risk from strokes and heart attacks. The report shows:

The report, commissioned by the Rheumatology Futures Project Group, analysed the views of more than 900 patients and 500 medical professionals and NHS staff. Some patients said they received 'no support' from specialist teams supposed to be co-ordinating their care and were just 'left on the sidelines'. The time between seeing a GP and seeing a specialist ranged from less than six months to more than three years.

But rheumatology experts are most concerned that the Government's 18-week target for referring new patients to specialists is having 'knock-on effects' for existing patients. This can leave those with long-term disease unable to get follow-up appointments because clinics are under pressure to reserve slots for new patients.

Professor David Scott, chief medical adviser of the National Rheumatoid Arthritis Society, said: 'Some GPs end up re-referring existing patients as "new patients" which costs their primary care trusts almost 250 pounds in payment by results instead of 99 as a follow-up appointment.' Professor Scott said he was not talking about his own trust but the experiences of many specialists nationwide. He said: 'Some patients are taking longer to get back to hospital than if they were a new patient, or under the old system. 'One problem is that rheumatoid arthritis is perceived to be a disease of old people and it's not. It can affect patients of any age but they struggle to get the care they need.'

Ailsa Bosworth, joint chairman of the Rheumatology Futures Project Group, said: 'Much needs to be done to raise awareness of the seriousness of this condition with the general public and to address the lack of clinical knowledge about rheumatoid arthritis in primary care.'

Dreamy NHS constitution sets out responsibilities for patients and staff

Any attempt to enforce it would be amusing -- and futile

A written constitution for the NHS - a bill of rights and responsibilities for patients and staff - will be officially signed by Gordon Brown and ministers at Downing Street today. A draft version has already been put out to consultation and the Government has tabled legislation to compel the health service to adhere to the final document. The constitution will effectively become a bill of rights for patients and was introduced by ministers as a major reform - comparable to Mr Brown giving the Bank of England control of interest rates when he was chancellor. The constitution sets out responsibilities linked to people's entitlement to free NHS care, including that they should take some personal responsibility for their own health.

But doctors and campaign groups say that the draft consisted of "optimistic pledges" that would not make any difference to patient care.

Alan Johnson, the Health Secretary, said yesterday that measures to tackle obesity would be included in the document but that it would not threaten to withhold treatment from those who were overweight through over-eating. It would not involve "broccoli police" to check up on people's eating habits. The constitution was intended to be "one concise, clear document that told people what their rights were, what their responsibilities were and what was expected of the staff," he said.

"We never intended this to change the way the NHS works, which is, if you have a health problem we will deal with it. "We have got a section in there on personal responsibilities but it's not something that's backed up by law and [therefore] you'll not have the broccoli police come round if you are having a fry-up. "It was never meant to be something that changed the health service and made it less acceptable to people and made it more problematic. "There are other ways of talking about the dangers of alcohol or getting your nutrition right than stating it in a constitution."

But Katherine Murphy, director of the Patients Association, said "We do not expect this document to make any difference to the care patients are receiving. The time for words like safety, quality, choice and, in this case, constitution to have the meaning they have elsewhere in life is long overdue."

National Voices, an association of charities and patients groups, said that the document had "huge potential". "We need a service that listens and responds to the needs of the people it serves."

Thursday, January 22, 2009

Health-Care Rationing in Britain

Bruce Hardy probably doesn't have long to live. But he could live longer, if it weren't for the attitude and policies of the British government. As recounted in a New York Times article, Mr. Hardy has kidney cancer that has spread to his lung. His doctor wanted him to take an expensive but effective new drug that has been shown to delay cancer progression for six months.

But Her Majesty's government refused the request. The Times reports: "If the Hardys lived in the United States or just about any European country . . . Mr. Hardy would most likely get the drug, although he might have to pay part of the cost. . . . But at that price, Mr. Hardy's life is not worth prolonging according to a British government agency, the National Institute for Health and Clinical Excellence." (In a supreme irony, the institute's acronym, NICE, is the same acronym C. S. Lewis used for the evil institute in his classic novel, That Hideous Strength.)

The Hardy case highlights many of the problems with socialized medicine: government rationing of health care, a lack of options, and an ultimate devaluation of human life. Remember, in most other countries, Mr. Hardy could have his treatment if he paid for part of it-but Britain isn't even giving him that choice. The government makes the health-care decisions. It's all out of his hands.

And the really scary thing is that other countries are starting to look to Britain as an example of how to manage health care!

Says the Times, "Top health officials in Austria, Brazil, Colombia and Thailand said in interviews that NICE now strongly influences their policies." And even here in the United States, some are calling for the adoption of some of NICE's practices, including officials with Medicare and Medicaid.

Way back during the Clinton era, I predicted that we'd have this kind of debacle here in America if the advocates of socialized health care got their way. As I pointed out then: "The truth is that capping costs will inevitably mean reducing services: Hospitals will have to stop using all the expensive medical technology. In plain English, they will have to stop treating so many people [that] people who are elderly, handicapped, or chronically ill will be pushed to the end of the line." Well, that's exactly what's happening to Bruce Hardy.

Yes, soaring health-care costs are a major problem, and we need solutions. But the great danger of systems like Britain's is that they invariably end up with the government performing a version of the old lifeboat exercise that so many children learn in school now: deciding whose life is worth saving and whose life should be thrown overboard. It doesn't matter how effective or efficient these systems may look on the surface. A government that takes upon itself the right to play God is a government that is not safe for its citizens.

"Everybody should be allowed to have as much life as they can," Bruce Hardy's wife, Joy, told the Times.

As we deal with our health care problems here in America, we would do well to remember her words. The goal of every government should be not to ration life, but to do everything possible to create a system that preserves it.

One of the untold stories of the Bush presidency is the progress that has been made over the last eight years on health reform. Though many other domestic and foreign policy issues have grabbed the headlines and many problems remain in our health sector, the administration and the Republican Congress have made notable progress.

In addition to several important policy changes, perhaps the most important accomplishment has been to create a climate friendly to innovation. Instead of offering promises of a sweeping, centralized overhaul of our health sector, President Bush took a step-by-step approach organized around his belief in individual freedom, free markets, competition, and choice. This has resulted in countless innovations from the private sector that have helped to moderate the rise in health insurance cost, create new models for care delivery and financing, and support the movement toward patient-centered health care.

Consider the progress that has been made in moderating costs over the last several years:

In 2007, U.S. health spending grew at its slowest rate since 1998, increasing just 6.1 percent, with year-over-year increases of 6.7 percent and 6.8 percent in 2006 and 2005.1 These increases are still higher than the general inflation rate, but not the double-digit spikes seen over the last several decades.

Premiums for private health insurance also rose by only 6 percent in 2007, the same rate as in 2006, but much lower than the peak of nearly 11 percent in 2002.2 Premiums for new consumer-directed health insurance plans introduced in this decade increased by much smaller amounts - 2.8 percent in 2005 and 2.6 percent in 2006 - helping to moderate costs overall.3

Change is indeed needed

There is a serious problem in our health sector: Health insurance and health care still cost too much. As a result, tens of millions of Americans don't have health insurance, and many more are worried they are one pink slip away from losing their coverage. The costs of Medicare and Medicaid are swallowing up a growing share of federal and state revenues, compromising other functions of government and threatening huge tax increases just to pay for current entitlement commitments. These and other challenges await the Obama administration.

But based upon the experience of this decade, the new president would be well advised to work for solutions that will offer greater choice of private health insurance in a market that continues to deliver innovation and quality of care. Because Americans consistently tell public opinion pollsters they do not want a larger role for government in the health sector, those policies that build on the private sector are much more likely to gain public acceptance.

A climate friendly to innovation

Continued innovation is vital in health care and health care delivery. The medical profession is moving toward patient-centered medicine, with micro-targeting of treatments tailored to the individual genetic code of individual patients. Advances in medical science demand that progress continue without being suffocated by the regulatory obstacles and restrictive payment systems now being considered in Washington. Instead, the government should continue to encourage more private-sector advances.

President Bush has consistently offered policy proposals based upon his belief that Americans should be empowered to make their own decisions about their health needs and that those needs will best be met if they have access to private health coverage that offers choice, flexibility, and incentives for quality health care. "In all we do, we must remember that the best health care decisions are made not by government and insurance companies, but by patients and their doctors," he said in his 2007 State of the Union address.4

A crossroads in the debate

The private sector is much more adept at innovation and evolutionary change than command-and-control public programs. But we are at a crossroads in the policy debate in this country where most of the proposals being offered by political leaders would exert much more centralized government control so that the private health sector would be forced to operate under largely the same rules as the public sector.5

Before we embark on that course, it would be wise to review what innovation has brought us and to assess whether we are ready to cast that aside to put much more control in the hands of public officials.

While the U.S. health sector continues to face many problems, this paper will do what few others have done and focus on the successes during a decade largely friendly to consumer choice and respectful of innovation. It is not possible to begin to describe all of the countless creative ideas, programs, and care delivery innovations in our $2.2-trillion health economy, but this paper will highlight some of the success in the private and public health sectors in this decade.

Two segments of the health sector

The U.S. health economy has two distinct segments - the public and private sectors - and each operates under different sets of rules. About 46 percent of the U.S. health sector is largely financed with tax revenues through government-operated programs, such as Medicare, Medicaid, the State Children's Health Insurance Program, the Veterans Health Administration, community health centers, and others. The rest of health care is financed privately, largely through businesses' contributions to support employment-based health insurance but also through direct purchase of insurance and out-of-pocket payments by patients.

Many analysts refer to our public and private health sectors as a health care system, but we do not have anything approaching a health system in the U.S. Rather, it is made up of conjoined twins, with one run by various government agencies and the other more reliant upon market forces. As health policy analysts attempt to achieve consensus on reforms for our health sector, it is becoming increasingly clear that this operational divide is one reason compromise is so difficult.

The government sector works primarily on a model that provides people eligible for public programs with an entitlement to a government-determined set of benefits within government-determined payment structures. Some patients receive care from physicians employed by the government in government-owned facilities, but most obtain care through private hospitals and physicians paid government-determined rates.

Within the public sector, private health plans also are involved. For example, many states have contracted with private managed care companies to offer care through their Medicaid and SCHIP programs, and Medicare allows participation by private plans in Medicare Advantage and the Part D prescription drug benefit program. But the majority of publicly-financed health care is delivered through the fee-for-service (FFS) model that the private sector largely left behind in the 1980s as unacceptably expensive and inefficient. The response of the public sector to these problems has been to place restrictions on benefits and payments to providers in an effort to restrain costs, which often result in patients having difficulty accessing services and providers.

The private health sector is much more diverse in its range of options and payment systems, representing an alphabet soup of program options from PPOs, POSs, MCOs, and HMOs to HSAs, HRAs, FSAs and even FFS.6 Private health plans, employers, and countless other companies in the health sector are continually innovating to provide options for care and coverage. But they are often constrained by regulation and also by tax policy that is better suited to the last century than to this one. This policy ties private health insurance to the workplace, restricting the market's responsiveness to consumer demands. This gives individual consumers less choice than they would have in a more competitive and open marketplace, as we have written in numerous papers, articles, and our book, Empowering Health Care Consumers through Tax Reform. (For more information see www.galen.org.)

While we do not have a properly functioning private market for health care in the United States, innovative ideas for improvements in the delivery and financing of health care nonetheless come largely from the private sector.

Health care traditionally is not an issue that Republicans have embraced. It is not clear if the issue would have received greater focus from the administration and Congress had the terror threat and the Iraq war not dominated the time and resources of the White House and the country. But the energy, investment, creativity, and responsiveness of the private sector we highlight below show that its engagement will be key to advancing positive change going forward.

Private sector innovation

Entrepreneurs and private investors have been making significant investment in new health care solutions: MinuteClinics, TelaDoc, specialty hospitals, innovative medical practices, and employer plans that empower consumers to engage in their health care and spending decisions are just a few examples in the innovation-friendly climate of this decade.

Here is a summary of some of the other countless private sector initiatives in care, financing, and delivery:

Employer innovations

Employers have taken giant steps to begin to get better value for spending on health care and health insurance for their employees. Some offer employees a variety of health plan options, allowing workers to decide whether they want to pay higher premiums for lower-deductible policies, for example, or agree to more restrictive panels of doctors and/or higher-deductible policies to save on premiums. The new products also give employers flexibility in shaping their health insurance offerings to fit their resources and workforces. A few examples:

Safeway chief executive Steve Burd has become an evangelist for consumer-directed health insurance arrangements. In the first year after the plans were introduced, the company's health costs went down 11 percent. "If you design a health care plan that rewards good behavior, you will drive costs down," he said.7 The company shared its cost savings disproportionately with employees, cutting their costs by 25 percent or more. Safeway also introduced a program called Healthy Measures that encourages employees to get health assessments and provides support and incentives for responsible health behaviors. Safeway also covers the full cost of recommended preventive care.8

Target offers its employees a range of health insurance choices. One Health Savings Account option costs them as little as $20 a month, and Target contributes $400 a year to health spending accounts for individuals and $800 for families.9 "We've seen, and national research supports, that team members make more cost-conscious decisions when they participate in a consumer-based plan," according to John Mulligan, Target's vice president for pay and benefits. "These plans engage our team members in a decision-making process that gives them greater ownership and control of their health care dollars." The company offers its 360,000 employees Decision Guides to help them compare price and quality and estimate their costs, plus access to wellness programs, a nurse hotline, and other support tools.10

Wal-Mart offers dozens of health plan options to its employees, one with premiums as low as $5 a month. For this, employees receive a $100 health care credit, more than 2,400 generic drugs available for $4 a month, and major medical coverage with no lifetime maximum that starts at $2,000 - basically the moment they step into a hospital. Employees can choose to pay higher premiums for lower deductibles and more comprehensive coverage.11 For $62 a month, employees can choose a $500 deductible policy with a $100 health care credit and no lifetime maximum on their insurance coverage.

Whole Foods' CEO John Mackey toured the country talking to employees about health benefits options. Afterward, employees voted to switch to new account-based health plans with higher-deductible insurance coverage. Whole Foods puts up to $1,800 a year into a spending account for each employee, with Mackey pointing out that this is not charity but part of the employee's compensation package. If they don't spend the money on medical care, it rolls over and the company adds more the next year. Some workers have as much as $8,000 in their accounts.12 Whole Foods saves money and still covers 100 percent of its employees' health insurance premiums.

These companies and many others have worked extraordinarily hard to find the delicate balance between getting health benefit costs under control and continuing to provide coverage that satisfies their workers. There simply is no way that a benefit or cost structure dictated by Washington could achieve these same results. Maintaining ERISA protection is crucial to allowing companies to continue to innovate.

Wednesday, January 21, 2009

Arrogant Therapeutic Goods Administration still refusing to cough up for its wrongful actions

The TGA is Australia's version of the FDA. They think that they can get away with destroying hundreds of businesses and creating huge financial losses on the basis of mere speculation. One of the grosser examples of bureaucratic irresponsibility and abuse of power. They are all the more hateful because they have settled with the "big" guy whom they hurt but now seem to think they can stiff all the the little guys by insisting on long drawn out and expensive court action. I have commented on the scum previously. Note that I am no fan of "alternative" medicine. As you can see here I think that there is too much quackery even in conventional medicine. But my attachment to the importance of evidence is obviously not shared by the TGA and the bitches who seem to run it -- depite scrutiny of evidence being their brief

PHIL Alexander has turned to the law for help five years after it was used against his naturopath business in the country's biggest medicines recall. He has become part of a $120 million class action against the commonwealth over its role in the collapse of Pan Pharmaceuticals, which once supplied his multivitamin business. "It was an incredibly harrowing experience," Mr Alexander said, recalling the 12,000 items of stock he was forced to destroy in the recall.

He even received death threats as frightened customers turned against him and bad publicity swamped his sales. "The odd father rang up and said 'If you kill my baby, I'll kill you'," Mr Alexander said.

In 2003, the Therapeutic Goods Administration suspended Pan's licence and progressively recalled 1600 of its products. The TGA accused Australia's then largest complementary medicine maker of substituting ingredients, manipulating test results and running sub-standard production lines after a Pan travel sickness drug was linked to 19 admissions to hospital.

But the decisions the authority made at the time were brought into serious question last year after the commonwealth settled with Pan founder Jim Selim for $55 million over the TGA's handling of the affair.

Now Mr Alexander wants redress, saying his once-thriving Sydney business has never recovered from the TGA's actions. "They pulled all the vitamins and minerals off the shelves, without cause," he said. "After 14 weeks, we were able to get stock made and get it back on the shelves, but of course over 30 per cent of our customers wouldn't come back."

Mr Alexander said the TGA had acted on an "ideological and regulatory whim" in ordering such a massive recall. He said Pan had passed a TGA audit not long before, and no complaints were made or illnesses recorded from the recalled products.

Mr Alexander said he first learned of his business's fate on the 6pm news one Monday in April 2003. "All hell broke loose, and the next day the phones went absolutely mad for 14 days. We spent months returning all the calls. It was bedlam, it was just insane," he said. The TGA refused to even test his multivitamins for contamination, despite ordering the destruction of his stock, Mr Alexander said.

A Health Department spokeswoman said yesterday the TGA was unable to comment because the case was before the courts. But the regulator has publicly refused to concede any of the allegations made in Mr Selim's lawsuit.

Susanna Khouri, investment manager with IMF Australia, which is funding the lawsuit, said Mr Alexander's story of lost revenue and emotional harm was repeated many times over.

Typical NHS short-sightedness. They pennypinch on drugs and as a result spend thousands dealing with avoidable fractures

The medicine regulator faces a legal challenge this week over its ruling that thousands of women with thinning bones should be denied effective treatment on the NHS. Draft guidance from the National Institute for Health and Clinical Excellence (NICE) states that doctors should prescribe the cheapest drug available to women with the early signs of osteoporosis, even though up to one in five patients cannot take it. The National Osteoporosis Society and the drug manufacturer Servier say that this is unethical and will do nothing to prevent fragility fractures that contribute to 13,000 premature deaths a year, as well as causing widespread disability and pain.

They will contest the NICE guidance in the High Court, as part of a full judicial review, claiming that the watchdog has not been transparent about its processes and is infringing the human rights of patients by denying them alternative medication on the ground of disability. NICE denies that it has acted illegally. But in a letter to The Times last September, 40 experts called on the watchdog to reconsider its decision, calling it "unethical and short-sighted".

Half of women and one in five men over the age of 50 will develop osteoporosis, in which the spine, wrist and hips become thin and fracture easily. While bone-strengthening drugs are available, the side-effects of alendronate, which costs 50 pounds a year, include crippling stomach pains and indigestion, while the medication is difficult to take - requiring patients to stand or sit for 30 minutes while it is absorbed. The guidelines mean that a woman in her early seventies who cannot tolerate alendronate would have to get up to 60 per cent worse - using a clinical scoring system - to qualify for strontium ranelate, an alternative medication that costs 17 pounds a month.

Nick Rijke, a spokesman for the National Osteoporosis Society, said: "Already there are more than 70,000 hip fractures a year which result in 13,000 deaths and cost the public purse 2.3 billion. "Yet with effective treatment, many of these fractures could be prevented, not only saving lives, but saving the taxpayer money at the same time."

Andrew Dillon, the chief executive of NICE, said that the recommendations on osteoporosis had been "a complex set of guidance to produce", but added that he was confident that NICE had acted lawfully and that the claim would be dismissed.

Tuesday, January 20, 2009

What Medicaid Tells Us About Government Health Care

Why would Obama want to build on a system with poor outcomes?

Medicaid provides coverage to poor and disabled Americans, many of whom face the highest burden of chronic disease owing to cultural and socioeconomic challenges. The program beats being uninsured, but it often relegates the poor to inferior care.

Reimbursement rates are so low, and billing the program so complicated, that it is hard for internists like me to get beneficiaries access to specialized care or timely interventions. For my patients as well, many of whom are uneducated or don't speak English, Medicaid is replete with paperwork, regulations and rejections that make the program hard to navigate.

Now Medicaid is to receive a bolus of federal money, probably as part of the fiscal stimulus plan -- the figure whispered in Washington is $100 billion -- with no obligation that the program does anything to reverse its decline.

Accumulating medical data shows that Medicaid recipients' poor health outcomes aren't just a function of their underlying medical problems, but a more direct consequence of the program's shortcomings. Take the treatment of serious heart conditions, which are among the most closely evaluated Medicaid services.

One study published in the Journal of the American College of Cardiology (2005) found that Medicaid patients were almost 50% more likely to die after coronary artery bypass surgery than patients with private coverage or Medicare. The authors suggest this may be a result of poorer long-term, follow-up care. Like other similar studies, this one tried to control for the other social and medical factors that are believed to influence patients' clinical outcomes.

Another study in the journal Ethnicity and Disease (2006) showed that elderly Medicaid patients with unstable angina had worse care, partly because they were less likely to get timely interventions or be treated at higher quality hospitals. Three other recent studies showed that Medicaid patients presenting with heart attacks or unstable angina received cardiac catheterization less often than Medicare or private paying patients. This procedure to open blocked heart arteries has become standard care, with ample evidence showing it improves outcomes.

The same trends can be observed in other diseases. For example, a study of adults with cancer published in the journal Cancer (2005) found that patients on Medicaid were two to three times more likely to die from the disease even after researchers corrected for differences in the location of the tumor and its stage when diagnosed.

The federal and state governments are equally culpable for the program's troubles. The federal government matches state Medicaid spending, paying an average of 57% of costs. States expand enrollment in order to qualify for more federal aid. Insurance coverage has become the end itself, with states spreading resources widely but thinly -- without enough attention to the quality of care, accessibility, or whether coverage was actually improving health. States have no obligation to rigorously measure health outcomes in order to qualify for more federal money.

A government survey in 2002 for the Medicare Payment Advisory Committee found that "approximately 40% of physicians restricted access for Medicaid patients" because reimbursement rates are so low. Only about half of U.S. physicians accept new Medicaid patients, compared with more than 70% who accept new Medicare patients. Several recent studies trace the difficulty in getting Medicaid patients seen by specialists to low fees and payment delays. Technologies are also restricted. Many expensive but important drugs aren't paid for under various state drug formularies.

There's also a fair degree of fraud in the program. James Mehmet, New York's former chief Medicaid investigator, was quoted in the New York Times as believing that at least 10% of state Medicaid dollars were spent on fraudulent claims, while 20% or 30% more was siphoned off by what he termed "abuse." Even if the federal government wanted to hold states more accountable for peoples' ?185 health, Medicaid claims data is poorly gathered in most states, making meaningful oversight hard.

Barack Obama's team and Democratic leaders plan to change the federal matching rate to reduce the amount of state funding that is required for maintaining a given level of federal Medicaid spending. Mr. Obama would give Medicaid tens of billions more in federal dollars as part of the fiscal stimulus bill. And he wants to extend Medicaid to some unemployed workers, with the federal government paying the entire cost -- a watershed expansion of the program. New money alone won't fix the program's woes. It will simply allow states to siphon off more of what they would have spent on Medicaid to other uses.

For its part, the federal government has often prevented the states from taking steps to fix their own Medicaid programs, such as by devising outcome-based standards for evaluating performance, and de-emphasizing the goal of growing the number of covered people to focus more on improving the health of those served.

Among a handful of states that have received "special permission" from federal regulators to take incremental steps to improve their Medicaid programs, North Carolina has created a primary care-based program that pays doctors more to improve coordination of care, and gives patients more choice by getting new doctors to participate in the program. Indiana is incorporating personal accounts that allow patients greater choice of providers.

Another idea being tried in some states allows patients to choose coverage tailored to specific health needs like pregnancy or certain disabilities. In Louisiana, Gov. Bobby Jindal wants to provide tailored Medicaid services through managed-care networks run by private and competing companies that would be held accountable for showing better health results.

The Centers for Medicare and Medicaid Services, which regulates the program, recently gave states the flexibility to redesign their Medicaid benefits by modeling the programs after popular private-sector plans already being offered in a particular state. But creating enduring incentives for broader state accountability probably means ending Medicaid's open-ended funding. Even the auto makers are being held accountable to certain outcomes as a condition for getting federal loans.

The troubling evidence about the quality of Medicaid patients' services is a cautionary tale for Mr. Obama as he sets about to administer more of our health care inside government agencies. Turning Medicaid around should be the least we demand before turning over more of our private health-care market to similar government management.

She was so miserable, she prayed she would live. She was so miserable, she prayed she would die. "Couldn't decide," her husband said later. On Jan. 4, three days after her emergency appendectomy, Jessica Baker, the morning traffic reporter for CFRB and EZRock, began experiencing excruciating abdominal pain - far worse than the pain she had in the hours before her appendix was removed - and vomiting repeatedly. At around 7:20 p.m., with Baker in the fetal position, her husband, Adam Dolgin, called 911. The ambulance, he said, arrived at their Toronto apartment more than 30 minutes later.

"It was awful. It was horrible. Probably the worst experience of my life," said Baker, who was hospitalized with a surgery-related infection. "I assume if anybody calls an ambulance, regardless of what it is - because who knows what it could have been, right - that 10, 15 minutes would be the longest it would take."

In all GTA municipalities, ambulances do respond to almost all "Code 4" 911 calls, those classified as the most urgent, within 15 minutes. But responses have become progressively slower over time - nowhere more than in Toronto. In 2007, Toronto responded to 90 per cent of Code 4 calls within 11 minutes, 58 seconds - 3:38 longer than its response time in 1996, according to Ministry of Health figures released upon request. Peel Region's response time increased by 2:38, from 9:32 to 12:10; York Region's increased by 1:26, from 11:38 to 13:04. With the exception of Durham Region, responses slowed throughout the GTA after Ontario downloaded ambulance service to municipalities in 2001.

Responses got faster in 27 of 50 Ontario ambulance jurisdictions between 2001 and 2007. But while numerous small towns and rural areas improved, the most populated urban areas generally regressed. The widespread increase in urban response times, said Emergency Medical Services officials, hospital doctors and the province, is largely the result of systemic problems outside EMS's control. Demand for ambulance care has boomed as cities have both grown and aged, far outpacing increases in EMS budgets.

Increasingly overburdened emergency rooms, unable to quickly find hospital beds for admitted patients, have become slower to take responsibility for people brought in by ambulance, forcing paramedics to continue to provide care instead of returning to the streets to respond to new calls. "Really, the ambulance response time problem is a symptom of the underlying problem: not enough capacity within the whole system. And it's predictable," said Dr. Dante Morra, medical director of the University Health Network's Centre for Innovation in Complex Care.

"The EMS group, and how they respond, is captive to how the hospitals act. The main problem here is that we do not have enough in-patient beds to take care of sick patients. ... These EMS people, who should just walk into the emergency, drop their patient off, and then leave, are frozen in the emerg for a long period of time, because there aren't enough resources there. But the problem isn't even an emerg problem. It's a flow problem."

Growth in the use of cellular and Internet phones, which do not provide automatic location information to ambulance dispatchers, has further contributed to a slower response times. While American cellular companies were forced to adopt location technology by 2005, Canadian regulators only this month imposed a 2010 deadline.

Norm Lambert, Toronto EMS deputy chief, said some of the worsening in Toronto's times - which increased by 44 per cent since 1996, 4 per cent since 2001 - is the result of a change in philosophy that emphasizes "a smarter response" as opposed to just a rapid response. For calls about heart attacks or choking, Toronto ambulances will scream to the scene. For reports of chest pain, however, the city will attempt to dispatch a team of expert paramedics equipped with cardiogram machines, even if that team is minutes farther from the victim than another ambulance. "In the past, we sort of always looked at it that if somebody phones in and it's considered an emergency, we want to run lights-and-siren to the call and get there as quickly as possible," Lambert said. "But that's not always the case. It's not a road race."

As elsewhere, he said, "off-load delay" - the time paramedics spend waiting to hand over patients in emergency rooms - plagues the city's response system. It cost EMS approximately 180 ambulance hours per day in December 2007. The Liberal provincial government has identified emergency room wait times as a priority. The province began in 2008 to provide funding to busy hospitals to devote nurses to the reception of ambulance patients - an "interim solution," the Ministry of Health said in an email. As a result, in December 2008 Toronto EMS lost 60 fewer hours per day to off-load delays. But the demand problem continues to escalate. In York Region, calls for ambulances are up 60 per cent since the municipality took over the service in 2000, said EMS general manager Norm Barrette.

In Toronto, now the 11th-fastest responder in Ontario, calls are up 23 per cent since 2002. Over the same period, Lambert said, the number of paramedics has increased only 1 per cent. "It gets back to resources and vehicle availability ... a 1 per cent increase in paramedics with a 23 per cent increase in demand is quite a difference." Ontario's 50 ambulance providers have been required by provincial law to match their 1996 response time for Code 4 calls - less than a third of which generally turn out to be actual life-threatening emergencies - in 90 per cent of cases. In 2007, only 17 of them met their targets, which the province considers "no longer relevant" to modern realities and which municipal governments have ignored to such an extent that some of them use different targets than the Ministry of Health. Toronto officials, for example, have long used a target of 8:59; the province lists it as 8:20.

As of 2011, municipalities will be permitted to set their own response-time targets for non-life-threatening problems, which will be made public. Municipalities will be urged, but not required, to meet ministry response guidelines for life-threatening problems. Richard Armstrong, director of Durham EMS, and Lambert both said the elimination of legislated targets would not reduce the incentive to improve response times. Voters, Armstrong said, would punish local politicians who set low standards in order to claim success in meeting them. "Through the combined accountability of municipalities to the ministry and to its residents, we believe the risk of such action - the filing of `easy-win' targets - is extremely low," the health ministry said.

An Alzheimer's patient lies in a grubby hospital bathroom because of a shortage of beds. Will the elderly EVER be treated with dignity in Britain?

This is the picture that shames the NHS. An elderly Alzheimer's patient is treated in a squalid bathroom due to a chronic shortage of beds at a hospital. In what her family describe as 'an affront to human dignity', Gladys Joynes, 79, was shunted into the bathroom for several hours. The grandmother was left next to an overflowing bin, a commode and a foulsmelling walk-in bath. And with no power point in which to plug in her saline drip equipment, she swiftly became dehydrated and unresponsive.

Mrs Joynes was taken to the Royal Liverpool University Hospital last Friday after falling ill with pneumonia-like symptoms at the nursing home where she is a resident. She arrived at the hospital's emergency department in the early hours but was not examined by a doctor until around 7am. Medical staff were unable to find a bed for her and at 10am she was placed in the bathroom. At 2pm her family arrived and were led to the bathroom. One of her three daughters, Sharon Huxley, 55, a company director, said: 'I was so shocked. It was a smelly bathroom with an overflowing bin and we had to put a tray of food on the floor and feed her ourselves from that. 'I just can't believe that staff are so desensitised and complacent that they didn't think it would be a problem.'

Mrs Joynes's eldest daughter, psychologist Kathleen Huxley, 57, said: 'It is a total affront to human dignity for her to be treated this way and the Government should ensure it does not happen again. 'We believe she was cynically chosen because she is an Alzheimer's sufferer and as such would not complain. 'What if an elderly patient or Alzheimer's sufferer hasn't got a family to stand up for them?'

Shadow Health Secretary Andrew Lansley said: 'It is extremely concerning if patients are not being treated with the respect and dignity they deserve. 'I know that the hard-working staff of the NHS will do everything they can to stop this from happening, but unfortunately their hands have been tied by Labour's complacent approach to the extreme pressures placed on our hospitals during winter. Years of bungling by Labour ministers have created a terrible legacy for NHS patients.'

The Daily Mail has consistently highlighted the plight of the older generation through its Dignity for the Elderly campaign. In recent weeks, our readers have also raised tens of thousands of pounds for Alzheimer's sufferers.

Mrs Joynes, 79, ran a milliner's shop in Liverpool before marrying Merchant Navy seaman Frank Huxley. After his death in 2002 she married Stewart Joynes, a musician, who also later died. She developed Alzheimer's symptoms about four years ago.

Last night Tony Bell, chief executive of Royal Liverpool University Hospital, said the hospital was dealing with an ' unprecedented' number of cases and said an extra ward with 17 beds had been opened to cope with the strain. Mr Bell said: 'I would like to offer the patient and her family our sincere apology. It is not acceptable for a patient to be put into a bathroom. 'We are now conducting a full investigation and will identify measures to prevent it happening to other patients.' The hospital denied that Mrs Joynes had been 'earmarked' for the bathroom because her condition meant she was less likely to complain.

Mrs Joynes was last night feeling a lot better and was about to be discharged. She was diagnosed with a chest infection.

Monday, January 19, 2009

Canada: Ambulance Delays Longer in Toronto

(Toronto, Ontario) According to the Ontario Ministry of Health, ambulance response times are becoming progressively longer, with Toronto exhibiting the worst performance, despite province-wide efforts to shorten them.

The widespread increase in urban response times, said Emergency Medical Services officials, hospital doctors and the province, is largely the result of systemic problems outside EMS's control.

Demand for ambulance care has boomed as cities have both grown and aged, far outpacing increases in EMS budgets.

Increasingly overburdened emergency rooms, unable to quickly find hospital beds for admitted patients, have become slower to take responsibility for people brought in by ambulance, forcing paramedics to continue to provide care instead of returning to the streets to respond to new calls.

"Really, the ambulance response time problem is a symptom of the underlying problem: not enough capacity within the whole system. And it's predictable," said Dr. Dante Morra, medical director of the University Health Network's Centre for Innovation in Complex Care.

"The EMS group, and how they respond, is captive to how the hospitals act. The main problem here is that we do not have enough in-patient beds to take care of sick patients. ... These EMS people, who should just walk into the emerg, drop their patient off, and then leave, are frozen in the emerg for a long period of time, because there aren't enough resources there. But the problem isn't even an emerg problem. It's a flow problem."

In summary, increases in demand for emergency services, coupled with the "off-load" delay times when paramedics must sit on their thumbs waiting for emergency rooms to accept patients, are causing ambulance response times to become longer.

From a nuts and bolts perspective, it appears that insufficient resources are being allocated to meet growing demand for emergency care and the situation is most notably exposed through increases in ambulance response times.

Background

Postings from Brisbane, Australia by John Ray (M.A.; Ph.D.) -- former member of the Australia-Soviet Friendship Society, former anarcho-capitalist and former member of the British Conservative party.

This blog gives a lot of attention to events in Australia and Britain -- places where there already exist systems similar to the one most likely to befall the USA if the Democrats get their way -- "Free" medical care supposedly available to all through government hospitals but with a competing private sector as well. The Canadian system is considered too Soviet to provide a likely model for the USA

TERMINOLOGY: Many of my posts concern the very instructive state of socialized medicine in Australia. Like the USA, Germany and India, Australia has a system of State governments which have substantial independence from the central (Federal) government and it is they who are mainly responsible for "free" health services. It may therefore be useful to some for me to note the standard abbreviations for the States concerned: QLD (Queensland), NSW (New South Wales), WA (Western Australia), VIC (Victoria), TAS (Tasmania), SA (South Australia).

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Conservatives do NOT object to helping the poor. Government welfare legislation in aid of the poor was in fact first introduced by conservatives -- Bismarck and Disraeli in the 19th century. What conservatives want is for the help to be delivered in a sane manner. And anyone who thinks that government bureaucracies can run hospitals well is completely out of touch with reality.

One of the oldest "free" public hospital systems in the world is that in the Australian State where I live: Queensland. It dates from 1944 (Britain's NHS began in 1948). So its advanced state of decay reveals well where the slow cancer of bureaucracy ends up. It now has three "administrative" employees for every medical employee. All those clerks are really good at curing people, I guess! Frequent bulletins on the flailing but ineffectual attempts to "fix" the system will appear here -- as well as bulletins on the dreadful things it does to patients and the long waits they endure.

On all my blogs, I express my view of what is important primarily by the readings that I select for posting. I do however on occasions add personal comments in italicized form at the beginning of an article.

I am rather pleased to report that I am a lifelong conservative. Out of intellectual curiosity, I did in my youth join organizations from right across the political spectrum so I am certainly not closed-minded and am very familiar with the full spectrum of political thinking. Nonetheless, I did not have to undergo the lurch from Left to Right that so many people undergo. At age 13 I used my pocket-money to subscribe to the "Reader's Digest" -- the main conservative organ available in small town Australia of the 1950s. I have learnt much since but am pleased and amused to note that history has since confirmed most of what I thought at that early age.

I imagine that the the RD is still sending mailouts to my 1950s address!

NOTE: The archives provided by blogspot below are rather inconvenient. They break each month up into small bits. If you want to scan whole months at a time, the backup archives will suit better. See here or here